Saturday, December 29, 2012

He spent a few hundred dollars on pizza and soft drinks. The setting was a little more lavish than usual, the servings more heaping. As I settled down with a piece of deep dish, he started his pitch.

Healthcare is changing. The little guys are joining hospital systems right and left. Regulation is getting out of hand. Why keep playing the same unsuccessful game? He offered a few hundred thousand to renovate the office, he would handle all the billing and staff, my only job would be caring for the patient. The perfect concierge practice.

His goal was to focus on the healthy and wealthy. No hospital work, no elderly or complicated. I would work less and make more. Of course, constant phone coverage would be necessary, and patients would have to be seen within twenty four hours. But the pay would be better, and the hassles would be minimal. Patients would be offered a cadre of services including full body CT scans and stress testing, but physician time would be mostly restricted to one hour evaluations.

Although I clearly had no interest in such a model, I had one important question.

Minus all the bells and whistles, what would I be offering that I don't offer them already?

He was more than prepared for this query. He rattled off a canned answer: same day appointments, rapid phone call return, personal attention, and a program that places a stress on wellness.

I thanked him kindly for lunch, and took a copy of his brochure. I perused it for a few minutes before jumping into my afternoon schedule.

I guess I just don't get this concierge thing. I already guarantee my patients same day appointments for almost anything. I return phone calls within thirty minutes. I take care of all my patients in both the hospital and nursing home. And I spend heaps of time concentrating on health and wellness, as well as death and dying.

The truth is, I don't know what I would add to my service to justify the costs required by most concierge practices.

I would just be asking them to pay me more. Pay me more to stay the same.

But believe it or not, in this ever changing healthcare system, this may be exactly what people crave.

Wednesday, December 26, 2012

I never said I didn't like the guy. In fact, the opposite was true. I respected Thomas for his career choice. Instead of residency or fellowship, he went to business school. Instead of hanging up a shingle, he worked towards a masters in public health.

Far be it from me to criticize his expertise. We need people like Thomas. The kind who expose the waste and absence of thrift. Maybe I rolled my eyes occasionally when he threw around Berwickian acronyms or sang the praises of the patient centered medical home. We are all entitled to our opinions; to use our knowledge to make a living.

So when Thomas limped into my office wincing in pain, I looked forward to interacting with this engaged and empowered patient. After taking a history and performing a physical exam, I felt fairly certain that he was suffering from a herniated disk. I sat at my desk across from the examining table and began to discuss the options. Seconds into my explanation, Thomas interrupted me.

I want an MRI!

I tried to explain that in absence of worrisome signs and symptoms, we could hold off on such testing until we got to the point of considering injections or surgery. I thought a man of his knowledge and outspoken views on parsimony would surely understand. There were a number of simple treatments to try first. Thomas wasted no time in responding.

I don't want surgery, but let's do the MRI just in case.

Would it surprise you to know that I spent the next twenty minutes trying to dissuade him? The MRI showed a herniated disk as expected. After a steroid dose pack and a few sessions of physical therapy, he was feeling better.

He strode into my office effortlessly two weeks later. His pain was gone. I gently chided, and asked if the MRI had been ultimately necessary. His smile barely quivered as he skirted the question, and reasserted his glorious improvement.

Saturday, December 22, 2012

The other day I was talking to a shrewd hospital administrator about the upcoming changes to our health care system. His eyes shown brightly as he proclaimed that now the name of the game was integration, enhanced communication. Why, in a matter of months the hospital would connect their EMR to the EMR of a number of skilled nursing facilities. Not only would that help the hospital qualify for meaningful use, it would usher in an era of higher quality and vertical integration.

Following his arguments, I wondered out loud. Although talking EMRs are wonderful, something is lost in translation when care is handed from one physician in one institution to a completely different physician in another. What if the hospitalists rotated through the local nursing homes and continued care in the post hospital setting. The administrator carried it even further, maybe those same hospitalists could also have a few hours of clinic time each week to follow up with newly discharged patients. That way, continuity and communication could be maintained through the whole spectrum of care.

He was really excited now, and started to dream about how his institution could rocket past his competitors into a new, efficient, quality driven model with zero voltage drop and minimal hand offs. The foibles of EMR generated communication gaps would be solved. Why mess around with making these huge, complex, voluminous systems talk when the real knowledge could remain in one or a small number of physicians heads. The ultimate accountable care organization.

I couldn't help laugh as I pretended to seriously ponder his suggestion.

You mean...the same doctor would take care of the patient in the hospital, nursing home, and outpatient settings?

He nodded his head vigorously as I continued.

You mean, like the system we had before the invention of hospitalists?

It took only moments to realize that I was teasing him. But as I walked away, I could see the confused look on his face as he pondered the reality of what I had just convinced him of.

The truth is, few people still believe that hospitalists provide more efficient or cost effective care. When taken as a whole, the studies suggest that when the costs of hospital and post hospital care are added, it comes out a wash. So why do we continue with the hospitalists model? Simple:

1)Hospitalists are great at implementing quality control initiatives and populating the EMR.
2)Hospitalists make eveyone's life easier, and allow primary care physicians an out from the arduous work of inpatient care.
3)Young physicians want to be hospitalists because of work life balance and the ease of having no long term responsibilities to patients. When your shift is over, your pager gets turned off.

I don't think the hospitalist movement is going anywhere. For better or worse, it is a model that is here to stay. But I think it's reached it's plateau. The new political goal is integrative care over multiple settings.

Wednesday, December 19, 2012

To the mother caring for the sickly child, his eyes will always be the sparkling iridescence of the school boy attending his first day of class. Although decades have passed and she is nearly eighty years old herself, he is not the middle aged man battling cancer, he is her son. Some parts of us are so delicate that even the mere threat of storm clouds can send us fleeing to safer climes. And when the unbreakable lies shattered at the feet of the mourning soul, we realize the frailty of love. We painstakingly relinquish the promise of dreams.

To the husband lying fetal on the death bed of his beloved, she is not the ancient beguiled by the failings of time. She is the sorority girl inching tepidly down the sweeping stairs unsure of the blind date that awaits below. The wrinkles only outline his vision of the porcelain skin from a time long ago. Souls may be inseparable, but bodies no longer cling with such great avidity.

Happiness is a goal to be strived for, yet pain is a much more reliable bedfellow. So we wander this earth half heartedly embracing the depths of our inner desires, half petrified of finding what we're looking for.

Sometimes I feel like I stand at a crossroads. I watch the misery play out around me. Such strength and such sadness.

Sunday, December 16, 2012

I have come to terms with making difficult decisions. I accept the possibility of committing a mistake that will cost a life. But I never signed on to bankrupting my patients. Never!

I had been up all night tossing and turning. The stat cat scan was deemed unnecessary by the insurance company. My patient called crying saying he couldn't afford the thousands of dollars in charges. Never mind the fact that the results suggested two life altering diagnoses. Feeling horrible, I called the hot line immediately and was told that the consulting physician would not be available till the next morning. Meanwhile, my patient was set up for an emergency consultation with the appropriate specialists.

My blood pressure began to rise the next day when my staff was still unable to reach the appointed doctor, the judge and jury deciding my patient's economic fate. I replayed the decisional process in my mind. Of course I could have done a chest xray and an ultrasound first. But given the acuity of the symptoms, I didn't feel like I could wait.
And indeed, the scan did exactly what it was meant to. It answered the pertinent question and allowed for immediate, possible life saving, action. But as I finally picked up the phone to argue my case, I felt my heart beating out of my chest. If I didn't perform, if I didn't say the right things, my patient would be saddled with unmanageable debt.

My vocal cords shaking, I answered the questions as best as I could. The businesslike voice on the other side of the line was steady and devoid of emotion.

But why a Cat Scan?

I again described how the acute shortness of breath, abdominal pain, and surprising physical exam mixed with the recent history of cancer was troubling. I waited in between long pauses for a verdict. Eventually, I was told that the interview was over. Helplessly, I sputtered out the question that rested so heavily on my brain cells for the last twenty four hours.

So are you going to cover it?

Impatiently, he explained that he wasn't able to give me a determination over the phone. The nurse coordinator would call my office back. As the words left his mouth a female voice chimed in who, unknown to me, had been monitoring our conversation.

Thank you Doctor for your time.

A few minutes later we received the call telling us that the cat scan would be covered.

This time.

I breathed a sigh of relief. Now, I could go back to dealing with the fact that his life and health would never be the same again. He was my next appointment.

Wednesday, December 12, 2012

He dreamed that his newborn child could sink comfortably into his beloved Grandpa Joe's arms. Months before the delivery, however, Joe suffered a debilitating stroke and his once mild dementia became catastrophic. He now wasted away in a nursing home. Unable to speak, feed himself, or dress, there was no sign of higher brain functioning.

Justin visited the home every weekend. He brought his growing son along hoping to spark a twinkle of life in his dying forebears eyes. The boy became a fixture in the home. The orderlies cooed and peek a booed as they found random reasons to engage him.

Justin was distraught. He missed the companionship of his grandfather dearly. The joy of parenthood, stained with the blemish of his suffering loved one, had lost its tarnish. If Joe could only speak to him. If only his baritone laugh could ring out like it once had when a young Justin took his sweet time.

The clock is ticking!

*

Early one morning as the baby played on a small area rug, a new doctor entered the room and approached Justin. He stood quietly and appraised the situation. His gray lab coat was wrinkled with the collar hiding his obscure complexion and darting eyes.

Quite a quandary.

He spoke without introducing himself. Justin strained to see his lips moving behind the fabric of the upturned collar. He nodded his head slowly, unsure what to make of this dark figure who abruptly entered his space. The doctor lowered his voice and spoke in a raspy whisper as he stared at the door.

What if it could all be different?

He took his right hand out of his pocket and produced a large oval pill. Justin grabbed the offering and examined it. It shimmered in the light of the adjacent desk lamp. It was plain, devoid of writing. The doctor instructed that if given to Grandpa Joe, he would wake up from the fog of dementia and become himself again. But the effect would be fleeting. The mysterious figure was already half way out the door before delivering the final pronouncement.

Three hours after taking the pill, he will fall back into his current state. Then he will die!

By the time he looked up, the doctor was gone.

Justin rolled the pill between his fingers and peered down at his son playing happily on the rug. Without hesitation, he slipped the pill into Joe's mouth and gently placed the water cup hoping the primitive swallow reflex remained.

And then he waited.

*

Moments later Grandpa Joe was alive! He hugged Justin and jumped out of bed to embrace his great grandson. As the child bounced in and out of his lap, he talked incessantly as if a long dead battery had been replaced somewhere deep in his bosom.

It will not serve the story to tell of all the things that were said in those three hours. The plans that were made. The promises that were kept. The unspoken words that suddenly found an outlet in reality.

But exactly three hours later, Joe got back into the bed seconds before his heart stopped.

*

Standing at the lectern reading the eulogy, Justin took a moment to survey the crowd of friends and family. Like with Grandpa Joe, he realized his time with each and every one of them was limited. As he finished his speech, he vowed to slow down and become better at being with those he loves. It was his grandfathers parting lesson.

Joe's voice echoed in Justin's ear while stepping down from the podium. His baritone laugh and mocking voice breaking the silence of the somber room.

Sunday, December 9, 2012

The eruption of papers fluttered to the linoleum floor of the bustling hospital corridor. Important persons with grey pressed coats and stethoscopes bouncing against clavicles rushed by without rotating necks downwards to notice. Loosely fitting scrubs clung to contracting muscles, and pudgy abdomens directed bodies hurriedly around the corner with a misplaced sense of purpose.

And the poor woman bent down helplessly, and struggled to collate the papers that had once fit nicely into her carrying case. Was she a hospital administrator? A researcher? A family member, back from the library, trying to study up on her loved one's illness?

No one took the time to find out.

A transporter pushing a gurney sped by and trampled an errant artifact that had flown away from the safety of the herd. The women wiped the sweat off her face, and blotted a tear with a crumpled hankie.

I was no less guilty. A few steps past, my mind swirling with one patient conundrum or another, I stopped mid stride. I turned around and silently knelt toward the ground. I gathered what was left on the floor and feebly handed it to the struggling woman. She looked up with injected conjunctiva and smiled anemically before I raised from the floor and moved on.

Am I any better? I have given myself a pass. I have used the nobility of a profession to deny the basic humility of grass roots kindness. How many times have I refused a donation to some odd cause or another by thinking: haven't I given enough?

Yet there is a strange lightness of heart that comes from the unrequired act of selflessness.

We health care professionals must remember that it doesn' take years of education or fancy gear to help our fellow man.

Wednesday, December 5, 2012

Sometimes words are like rain drops, tears, that bounce off the umbrella and splash to the ground fraudulently.

Some barriers are unable to be breached.

*

He was intense. His arms swung rapidly in opposite directions as he talked. Words whizzed out of his mouth like formula one cars, shooting past me and often missing their target. His physical presence was far smaller than his spiritual. Yet he was an immense man. His brutish exterior hid a much kinder and gentler soul.

He was rough around the edges.

He tolerated the antibiotics just fine, but this was his third bout of diverticulitis. The last was particularly severe. I wrote the referral for the surgeon, and placed it in front of him. He read the name quietly and looked up at me.

Surgeon, why do I need a surgeon?

I carefully explained how the nature of his recurrent infections necessitated surgery. His posture changed dramatically after the "s" word parted my lips. His colorful face mimicked his language as he spouted uncontrollably.

Surgery, surgery...Fuck You!

I could see the look of surprise and regret before he sputtered a pressured apology.

*

It was really rather offhanded.

I had called to relay the latest results of her daughter's blood tests. Everything looked fine. She breathed a sigh of relief. The hospitalization of her twenty year old child was enough to send her over the edge.

But she survived. They survived. And likely this was the end of a trying but hopefully not scarring episode in their lives. We chatted for a few minutes before hanging up. I had taken care of one or another family member for the last decade. There was a certain familiarity.

As we went to say our parting goodbyes, she paused for a moment.

Doctor G, you know we really love you!

I thanked her and hung up the phone. My mobile was ringing, the front desk was over heading me, and the computer was flashing.

Saturday, December 1, 2012

The secret sauce of medicine, I figured, was becoming an excellent diagnostician. I devotedly memorized the signs and symptoms, the pathways and algorithms. I strained to differentiate the pain in the chest due to suffocating myocardial cells from the stretching of the pleura or the lack of serotonin in the brain. I cut my teeth on those early patient encounters. Each experience was like a bookmark, a highlighted passage from a sacred tome.

I was blindsided by the realization that there was something else. Something just as important. And to my dismay, the art of prognostication proved to be just as complicated. When I talk of the master prognostician, I'm not referencing one skilled at matching diagnoses to life expectancy charts. This is the work of the accountant, the actuary.

I'm referring to the innate ability to understand when a person is dying. Without such knowledge, our profession becomes the fodder of technicians. Hands meant for healing can also do great harm. How are such hands restrained?

There is a tipping point. Once past this imaginary line, aggressive intervention heightens pain and decreases quality and duration of life. There is a reversal of physiology. Cure becomes the poisonous draught of good intentions.

We suffer a blindness to the important skill of prognostication. We don't recognize or acknowledge the tipping point. We hang on hope and deny reality. It's easier that way.

Chemotherapy drip drips.

Scalpels snip snip.

Overzealous hands provide underwhelming outcomes.

It's an uncertain skill. It can't be gleaned from text books or defined by lab values. We learn through experience. A strange mixture of clinical information, familiarity, and intuition makes some better than others.

But if you really want to help your patients, learn how to recognize death's distant footsteps.